The Suleman Octuplet Case: An Analysis of Multiple Ethical Issues

  • M. Sara Rosenthal
    Correspondence to: M.S. Rosenthal, PhD, Program for Bioethics, Department, Internal Medicine, Suite K522, University of Kentucky, 740 South Limestone Street, Lexington, Kentucky 40536-0284. Phone: 859-257-9474; fax: 859-257-2605.
    Program for Bioethics, Department, Internal Medicine, University of Kentucky, Lexington, Kentucky
    Search for articles by this author


      The Suleman octuplet case is the first reported case in which surviving octuplets were born as a result of in vitro fertilization and embryo transfer. In this case, the octuplets were born to an American single mother of six children, who was on public assistance, and who used a sperm donor. This has raised multiple ethical questions, which include the ethical obligations of the health care providers involved, the informed consent process, as well as moral obligations of the mother to her existing children and unborn children. This case analysis provides a clinical ethics and prenatal ethics framework, based on relevant American media and public documents available from January 26, 2009, to January 26, 2010, the period of time in which media scrutiny of this case was most relevant. Although this analysis introduces broader ethical implications, it is not intended as a philosophical discourse regarding the rights of patients to reproduce or the rights of society to place limits on who can and who cannot reproduce; neither is it intended as an in-depth policy review of reproductive technologies. Rather, this analysis focuses on clinical ethics breaches in this particular case, which led to an unintended outcome. The relevant clinical ethical principles, duties, and obligations are identified, with recommendations for a preventative ethics approach in the absence of clear policies that regulate embryo transfer.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Adams, T. (2002). When the Story's Over, The Guardian, January 27. Available: http://wwwguardiancouk/theobserver/2002/jan/27/featuresmagazine57. Accessed February 16, 2009.

        • Ahner R.
        • Bikas D.
        • Rabl M.
        • Al-Kouatly H.B.
        • Krauss A.N.
        • McCullough L.B.
        • et al.
        Ethical implications of aggressive obstetric management at less than 28 weeks of gestation.
        Acta Obstetricia et Gynecologica Scandinavica. 2001; 80: 120-125
        • American Society for Reproductive Medicine (ASRM)
        Guidelines on number of embryos transferred.
        Fertility and Sterility. 2008; 90: S163-S164
      2. Assisted Human Reproduction Canada. (2009). Available: Accessed February 16, 2009.

        • Bessner R.
        State intervention in pregnancy.
        in: Basen G.E.M. Lippman A. Misconceptions: The social construction of choice and the new reproductive technologies, volume 2. Sean Fordyce, Hull, Quebec1994
        • Brown S.D.
        The "fetus as Patient": A critique.
        The American Journal of Bioethics. 2008; 8: 47-49
        • Campbell D.M.
        • Templeton A.
        Maternal complications of twin pregnancy.
        International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics. 2004; 84: 71-73
        • Caplan A.L.
        And baby makes moral muddles.
        in: Caplan A.L. Am I my brother's keeper? The ethical frontiers of biomedicine. Indiana University Press, Bloomington1997
        • Chervenak F.A.
        • McCullough L.B.
        Legal intervention during pregnancy.
        JAMA. 1991; 265: 1953
        • Chervenak F.A.
        • McCullough L.B.
        Selective termination down to a singleton pregnancy.
        Ultrasound in Obstetrics & Gynecology. 1992; 2: 231
        • Chervenak F.A.
        • McCullough L.B.
        Ethical implications for early pregnancy of the fetus as patient: A basic ethical concept in fetal medicine.
        Early Pregnancy. 1995; 1: 253-257
        • Chervenak F.A.
        • McCullough L.B.
        The fetus as a patient: an essential ethical concept for maternal-fetal medicine.
        The Journal of Maternal-Fetal Medicine. 1996; 5: 115-119
        • Chervenak F.A.
        • McCullough L.B.
        Ethics in obstetrics and gynecology. An overview.
        European Journal of Obstetrics, Gynecology, and Reproductive Biology. 1997; 75: 91-94
        • Chervenak F.A.
        • McCullough L.
        Ethical implications of the embryo as a patient.
        in: Kurjak C.F. The embryo as a patient. Parthenon Publishing, New York2001
        • Chervenak F.A.
        • McCullough L.B.
        The fetus as a patient: An essential concept for the ethics of perinatal medicine.
        American Journal of Perinatology. 2003; 20: 399-404
        • Chervenak F.A.
        • McCullough L.B.
        Professional integrity, respect for autonomy, and the self-regulation of reproductive endocrinology.
        American Journal of Obstetrics and Gynecology. 2009; 201: 3
        • Chervenak F.A.
        • McCullough L.B.
        • Wapner R.J.
        Selective termination to a singleton pregnancy is ethically justified.
        Ultrasound in Obstetrics & Gynecology. 1992; 2: 84-87
        • Chervenak F.A.
        • McCullough L.B.
        • Wapner R.
        Three ethically justified indications for selective termination in multifetal pregnancy: A practical and comprehensive management strategy.
        Journal of Assisted Reproduction and Genetics. 1995; 12: 531-536
        • Chervenak F.A.
        • McCullough L.B.
        • Rosenwaks Z.
        Ethical dimensions of the number of embryos to be transferred in in vitro fertilization.
        Journal of Assisted Reproduction and Genetics. 2001; 18: 583-587
        • Chervenak F.A.
        • McCullough L.B.
        • Rosenwaks Z.
        Ethical considerations in newer reproductive technologies.
        Seminars in Perinatology. 2003; 27: 427-434
        • Collini S.
        On Liberty and Other Writings.
        in: Mill J.S. Cambridge University Press, New York City1989
        • DePalma A.
        The babies of quintland now: Broke and bitter.
        The New York Times. 1998, March 4;
        • Dickens B.M.
        • Cook R.J.
        Dimensions of informed consent to treatment.
        International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics. 2004; 85: 309-314
        • Dionne A.
        • Dionne C.D.
        • Dionne Y.
        Advice from the Dionne quintuplets.
        Time. 1997;
        • Etchells E.
        • Sharpe G.
        • Burgess M.M.
        • Singer P.A.
        Bioethics for clinicians: 2.
        Disclosure. CMAJ. 1996; 155: 387-391
        • Etchells E.
        • Sharpe G.
        • Elliott C.
        • Singer P.A.
        Bioethics for clinicians: 3.
        Capacity. CMAJ. 1996; 155: 657-661
        • Etchells E.
        • Sharpe G.
        • Walsh P.
        • Williams J.R.
        • Singer P.A.
        Bioethics for clinicians: 1.
        Consent. CMAJ. 1996; 155: 177-180
        • Pennings G.
        • de Wert F.
        • Shenfield J.
        • Cohen B.
        • Tarlatzis P.
        • Devroey P.
        • European Society of Human Reproduction and Embryology Task Force
        ESGRE Task Force on Ethics and Law 13: The welfare of the child in medically assisted reproduction.
        Human Reproduction. 2007; 22: 2585-2588
        • Fleischman A.R.
        • Chervenak F.A.
        • McCullough L.B.
        The physician's moral obligations to the pregnant woman, the fetus, and the child.
        Seminars in Perinatology. 1998; 22: 184-188
        • Hack M.
        • Flannery D.J.
        • Schluchter M.
        • Cartar L.
        • Borawski E.
        • Klein N.
        Outcomes in young adulthood for very-low-birth-weight infants.
        New England Journal of Medicine. 2002; 346: 149-157
        • Hamersley S.L.
        • Coleman S.K.
        • Bergauer N.K.
        • Bartholomew L.M.
        • Pinckert T.L.
        Delayed-interval delivery in twin pregnancies.
        The Journal of Reproductive Medicine. 2002; 47: 125-130
        • Hull R.T.
        The alchemy of informed consent.
        The Journal of Clinical Ethics. 2002; 13: 63-66
      3. Human Fertilisation and Embryology Authority. Available: Accessed February 16, 2009.

        • Jones J.W.
        • McCullough L.B.
        • Richman B.W.
        Informed consent: it's not just signing a form.
        Thoracic Surgery Clinics. 2005; 15: 451-460
        • Khan R.
        • Indrees M.
        • Palamarchuk T.
        • Dawlatly B.
        Successful term delivery of the second twin after rescue cervical cerclage at 21 weeks with the placenta of the first twin in situ.
        Journal of Obstetrics and Gynaecology. 2008; 28: 346-347
        • Klotzko A.J.
        Medical miracle or medical mischief? The saga of the McCaughey septuplets.
        Hastings Center Report. 1998; 28: 5-8
        • Lemonick M.D.
        It's a miracle.
        Time. 1997;
        • Loewy E.H.
        In defense of paternalism.
        Theoretical Medicine and Bioethics. 2005; 26: 445-468
        • Lyerly A.D.
        • Little M.O.
        • Faden R.R.
        A critique of the ‘fetus as patient’.
        The American Journal of Bioethics. 2008; 8: 42-44
        • Lyman R.
        Mother of the octuplets goes home to recover.
        The New York Times. 1998;
        • Mahowald M.B.
        Noncompliance during pregnancy.
        in: Mahowald M.B. Bioethics and women across the lifespan. Oxford University Press, New York2006
        • McCullough L.B.
        • Chervenak F.A.
        Ethics in obstetrics and gynecology.
        Oxford University Press, New York1994
        • McCullough L.B.
        • Chervenak F.A.
        Response to commentaries on "A critical analysis of the concept and discourse of "unborn child".
        The American Journal of Bioethics. 2008; 8: W4-W6
        • Meyers C.
        Cruel choices: Autonomy and critical care decision-making.
        Bioethics. 2004; 18: 104-119
        • Minkoff H.
        • Ecker J.
        The California octuplets and the duties of reproductive endocrinologists.
        American Journal of Obstetrics and Gynecology. 2009; 201 (15.e1–e3)
      4. Mohajer, S.T. (2010, January 5). Michael Kamrava charged with gross negligence. Associated Press.

        • Purdy L.M.
        Genetics and reproductive risk: Can having children be immoral?.
        in: Purdy L.M. Reproducing persons: Issues in feminist bioethics. Cornell University Press, Ithaca, NY1996
        • Purdy L.M.
        Could there be a right not to be born an octuplet?.
        in: Noggle S.B. Taking responsibility for children. Wilfred Laurier Press, Waterloo, Ontario2007
        • Ory S.
        The American octuplet experience: A transformative event.
        Fertility and Sterility. 2010; 93: 337-338
        • Rosenthal M.S.
        A preventive ethics approach to IVF in the age of octuplets.
        Fertility and Sterility. 2010; 93: 339-340
        • Schieve L.A.
        • Meikle S.F.
        • Ferre C.
        • Peterson H.B.
        • Jeng G.
        • Wilcox L.S.
        Low and very low birth weight in infants conceived with use of assisted reproductive technology.
        New England Journal of Medicine. 2002; 346: 731-737
        • Schieve L.A.
        • Peterson H.B.
        • Meikle S.F.
        • Jeng G.
        • Danel I.
        • Burnett N.M.
        • et al.
        Live-birth rates and multiple-birth risk using in vitro fertilization.
        JAMA. 1999; 282: 1832-1838
        • Scruby A.
        Radio psychiatrist files complaint against octuplet mom.
        Whittier Daily News. 2009, February 17;
        • Skupski D.
        • Chervenak F.A.
        • McCullough L.
        An ethically justified decision-making pathway for the management of pregnancies complicated by twin-to-twin transfusion syndrome.
        Fetal Diagnosis and Therapy. 2007; 22: 339-342
        • Sorenson C.
        ART In the European Union.
        Euro Observer: The Health Policy Bulletin of the European Observatory on Health Systems and Policies. 2006; 8: 1-8
        • Soucy J.
        • Dionne Y.
        • Dionne C.
        Family secrets: The Dionne quintuplets' autobiography.
        Berkley, New York1997
        • Strong C.
        Ethics in reproductive and perinatal medicine: A new framework.
        Yale University Press, New Haven1997
        • Strong C.
        Octuplets and Ethics.
        Fertility and Sterility. 1999; 72: 970-972
        • Strong C.
        Do Embryonic "patients" have moral interests?.
        The American Journal of Bioethics. 2008; 8: 40-52
        • Tauber A.I.
        Sick autonomy.
        Perspectives in Biology and Medicine. 2003; 46: 484-495
        • Veatch R.M.
        Abandoning informed consent.
        Hastings Center Report. 1995; 25: 5-12
        • Veleva Z.
        • Karinen P.
        • Tomas C.
        • Tapanainen J.S.
        • Martikainen H.
        Elective single embryo transfer with cryopreservation improves the outcome and diminishes the costs of IVF/ICSI.
        Human Reproduction (Oxford, England). 2009;
        • Wapner R.J.
        • Davis G.H.
        • Johnson A.
        • Weinblatt V.J.
        • Fischer R.L.
        • Jackson L.G.
        • et al.
        Selective reduction of multifetal pregnancies.
        Lancet. 1990; 335: 90-93
        • Yoshino K.
        Doctor who treated octuplets mom ejected from Society of Reproductive Medicine.
        Los Angeles Times. 2009, October 20;


      M. Sara Rosenthal, PhD, is Associate Professor, Bioethics and Director, Program for Bioethics at the University of Kentucky College of Medicine. She is Chair of the University of Kentucky Medical Center's Hospital Ethics Committee and directs the clinical ethics consult service.